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As l read Lifebox chair and co-founder Atul Gawande’s editorial published in the Lancet Commission on Global Surgery I am reminded of this moment: our part in a global chain reaction sparked in desperate response to the challenges faced by Dr Shrikant Jaiswal, first and only anaesthetist at Umarkhed Hospital in India.

Umarkhed is the closest hospital to the rural village where Atul’s father grew up. It serves a community of over 60,000 people in the town and a quarter million others in surrounding areas, and, as he wrote in a recent Lancet article “like so many hospitals in low-income settings, [it did] not have essential monitoring systems – even just a pulse oximeter.”

Pulse oximeters are the single most important monitors in modern anaesthesia, allowing healthcare workers to ensure their patients are adequately oxygenated and stable. The Lancet Commission on Global Surgery, a year-long, collaborative research effort into the issue chose pulse oximetry as a proxy measure for safety in surgery: it’s a machine with enormous practical and symbolic value, and a key component of Lifebox’s safer surgery work.

“Listening to Dr Jaiswal on the phone, I realised that for all the communities Lifebox had helped, we had not helped the community where my own family had come from,” Atul wrote in the Lancet.

“How fast could we get three oximeters to reach the frontline in India?” he wrote to us.

This moment also represents team work – it shows how a small group of people working together in a shoebox office in London respond to the needs of medical professionals, like Jaiswal, all over the world.

Since 2011, Lifebox has distributed nearly 9000 pulse oximeters to hospitals in 90 countries – working with anaesthetists, surgeons and healthcare professionals across low and high resource settings to ensure that more communities have access to safer surgery.

When Atul’s email came in, the next step was to pass on to Lifebox Procurement Manager, Remy Turc. Remy handles the distribution of pulse oximeters, ensuring that this essential piece of monitoring equipment makes its way from our manufacturer in Taiwan, to hospitals in low resource settings.

“I gave Lifebox Jaiswal’s address and made a donation for three oximeters to be delivered,” explained Atul.

Thanks to a collaborative effort, in just over a week Jaiswal received the three pulse oximeters he so desperately needed in order to provide life-saving treatment – one for the operating theatre, one for the labour ward and one for the recovery room.

His story powerfully demonstrates the changing global health landscape. For the first time in history you’re more likely to be killed by a surgically treatable condition than a communicable disease; but in low resource settings surgery can be a challenge to access and desperately unsafe.

The recent launch of the Lancet Commission on Global Surgery, culminating in a report that aims to put the problems of essential surgery at the heart of the global health agenda offers a rallying call – Universal access to safe and affordable surgical and anaesthesia care for all when needed.

According to this report five billion people cannot access safe surgery when they need it, with 33 million others facing catastrophic expenditures paying for surgery and anaesthesia annually.

There are huge challenges ahead but the dedication of people like Jaiswal is what keeps us going here at Lifebox. We are committed to the distribution of essential monitoring equipment, education and training – to saving lives though safer surgery.

More than 1,500 Rotarians from across the country gathered in sunny Belfast at the Waterfront Conference Centre, a grand venue with its toes on the edge of the beautiful River Lagan. They came for a weekend of talks, presentations, voting – and of course to support worthy causes both in the UK and around the world.

We were thrilled to share our safer surgery story, and to stand amongst a number of great organisations, including our good friends Mercy Ships, who we’ve recently worked with in Madagascar.

There are two important things we’ve learnt about Rotarians over the last few years: firstly, they’re a network of enthusiast, caring individuals with a passion to support communities around the world. From providing humanitarian assistance to fundraising for local hospices, Rotary clubs and members engage with a diverse range of community issues.

Secondly, Rotarians appreciate practical initiatives – and we are not too humble to admit that the Lifebox pulse oximeter was a crowd pleaser at this year’s conference! Rotarians beelined to our stand to get their blood oxygen saturation checked, lured by the bright yellow box in middle of the table.

Most had a number of questions about our work, summed up in typical Irish style: What’s the craic? (No translation necessary for the initiated and quick clarification for the rest of you!)

Our response: safer surgery of course.

As word spread about the pulse oximeter, thanks to the help of Lifebox champions/dedicated Rotarians/proud parents Lindsay and Barbara Bashford, more and more people visited our stand to learn how this vital piece of equipment is saving lives.

Since 2011, Lifebox has distributed nearly 9000 pulse oximeters to hospitals in 90 countries – working with anaesthetists, surgeons and healthcare professionals across low and high resource settings to ensure that more communities have access to safer surgery.

Thanks to Rotarians’ generous support, more pulse oximeters are now whizzing across the globe to hospitals where they are desperately needed. We are closing the pulse oximetry gap slowly but surely, and we won’t stop until every operating theatre in a low-resource setting has this essential monitoring tool, the training to use it appropriately, and the safety systems in place that keep patients safe.

We had a wonderful time in Belfast meeting all the Rotarians who are helping us to make safe surgery happen, finding new Rotary friends and learning about the diverse range of projects they support. We hope they enjoyed meeting us too.

Here’s to an even sunnier conference – and a bigger beach – in Bournemouth next year!

It’s late on a Monday and l’ve been scrolling through my Twitter feed for the past hour. I don’t normally spend this much time on one Twitter session but it’s almost as if I’m reading a book that I just can’t put down! The reason for this: it’s the night after International Women’s Day. March 8th, a date that has become increasingly important on my calendar over the last few years.

For me, this one day in the year is symbolic of a global effort to recognise and celebrate the achievements of women and girls all over the world, and to shine a light on the injustices they continue to face. And since joining Lifebox Foundation as a Communications Assistant in January, I’ve learned about a new one: unsafe surgery.

For the first time in history you’re more likely to be killed by a surgically treatable condition than a communicable disease, but in low resource settings surgery can be a challenge to access and desperately unsafe. And all too often, women bear the brunt.

Social media has become a powerful tool for sharing these experiences. And across great distances, it mobilises us all, encourages us to advocate for change. Sometimes it begins with just one story.

So when my colleague Sarah and I were planning our social media campaign for International Women’s Day this year, we really wanted to share the stories of some of the colleagues we work with around the world. Women whose stories, from the forefront of the global crisis in unsafe surgery, show change in action.

I’m still new to the world of a surgery and anaesthesia, but I quickly saw why this year’s IWD theme, ‘Make it Happen,’ is so fitting. Unsafe surgery is a global crisis, and our colleagues around the world aren’t waiting to be told to fix it. They’re busy taking action.

Take Dr Ronke Desalu who works as a consultant anaesthetist at Lagos University Teaching Hospital. “I work in a 770 bed teaching hospital,” she explained, “and along with some colleagues was instrumental in establishing the use of the WHO Surgical safety checklist in my hospital.”

This essential checklist has been proven to reduce surgical complications and mortality by 40 percent.

Or Dr Sandra de Iziquierdo from Guatemala, who told us that this year she aims to “introduce the use of pulse oximeters in five public hospitals with the highest maternal mortality rates.”

Distribution of pulse oximeters, training and education is a crucial part our work here at Lifebox – this robust tool means that anaesthesia providers in low-resource settings can confidently monitor their patients’ oxygen and blood saturation levels during surgical procedures.

Over the last two weeks our Twitter and Facebook pages have been bursting with action, with ambition, with compassion and with the voices of women at the forefront of safer surgical care in their communities. There is so much work for them to do.

As I sat there scrolling, tweet after tweet, the resounding message about gender equality I took away is this – we must do more. But then I thought about that day a few weeks back, when we emailed our colleagues to ask, ‘what are you doing right now to make surgery and anaesthesia safer?’ The answers came back so suddenly, so powerfully, so engaged. These women are already working to make it happen.

Who are these brilliant individuals, advocating for global surgery at home and on the world stage? Click here to find out!

In 2010 we sent him our first pulse oximeter. Lifebox wasn’t even Lifebox back then – it was the Global Pulse Oximetry Project, fresh from a worldwide tendering process led by WHO and the WFSA for an ideal monitor to thrive in low-resource settings.

We were perched on a desk in a third floor room at the AAGBI in London, figuring out what to do next.

Sure, we had our oximeter – robust, intuitive, with an education package, rechargeable batteries and a bright yellow glow – but no clear ordering system, no troubleshooting guide – and no proven plan for delivery.

If we had a hope of closing even one Operating Room’s pulse oximetry gap (let alone the gap in 77,000), we needed to design and test our systems beyond reproach.

Ray Towey understood.

A British anaesthetist, he’d been working in Africa for more than 20 years – first in Tanzania and then in northern Uganda.

He took one of the first modern hospital pulse oximeters in his rucksack to St Mary’s Lacor in Gulu, a large church hospital, back in the 1980’s. It cost about £2000.

“I started anaesthesia in 1968 – I’m old enough to remember giving it before oximetry. And in poor countries, people were dying from hypoxia before we noticed, particularly people with dark skin. So when the oximeter came, we knew we couldn’t do without it. First we carried one, then another,” he told us.

“People die when you don’t have one in the operating room,” he explained, sitting forward on the couch during a visit to the AAGBI. “And we give inappropriate oxygen therapy when we don’t have the oximeter in the neonatal unit.”

People die, that is, from conditions that would be treated and discharged as a matter of routine in Western Europe. They die from treatments that are supposed to save them, because the safety mechanisms aren’t in place.

As a medical professional – seeing this, knowing this – how do you move between worlds and not break down?

Ray Towey is an activist.

“I’ve been very active in the peace movement in the U.K. I was in jail in the 1980’s, active in the CND doing protest and resistance – the obscenity of nuclear weapons, what a waste of life and energy.

I never learned to live with the indifference of my culture. But I live with that as – a dissident. So as a dissident I’m doing my best to make the changes here. And as a healthworker.”

He took action at St Mary’s. Working with colleagues in the OR, in the ICU. Today the hospital hasn’t had a death on the operating room table in current students’ memory. They’re saving patients who would never be saved without their teamwork and systems. The challenge remains to reduce complications in the post-operative period. But that knowledge, that teamwork – that makes it worthwhile.

Ray Towey is a humane man.

“When I lose a patient it hurts very much. And sometimes when you lose a patient in some particular situation – especially when they’re young – it hurts a lot.

I walk through the waiting room of the intensive care unit in Gulu about five times a day. And because I know a certain percentage are going to die, sometimes I can’t look them in the eye.”

it didn’t arrive. Not the first week, or the second. Or the first month, or the second.

Thanks to Ray we had our answer and our system. Since 2010 all Lifebox oximeters have been shipped by courier service. It’s a bit more expensive, but it’s the only way to guarantee that our equipment arrives in the hands of the people who use it, and on the fingers of the patients who need it, as soon as possible.

We sent a new shipment to Ray.

“The concept of giving an anaesthetic without an oximeter is like not wearing shoes on the streets of central London,” he explained. “It’s just inconceivable that anyone would want to do that.

With more than 8,300 oximeters distributed to 90 countries around the world since, we haven’t lost a package.

In the spring of 2011 we got an email from Ray, and a photo.

“We used one of the oximeters on a sick neonate which is a big test. It did a good job for us. I think its got excellent software and was a good choice.”

P.S. Not wishing to do injustice to the postal service or the value of every donation – believe it or not, the first shipment arrived! Three months later, surfacing in the Post Office in Kampala. But we still use a courier service – 77,000 operating rooms around the world have already waited long enough.

The 70,000 global pulse oximeter gap keeps us busy. Not a day goes by without a Lifebox oximeter winging its way across earth and sea and sky to anaesthesia providers in the most remote hospitals worldwide, delivering life-saving surgery without this life-saving equipment.

But some days the skies are heavier than others!

In October 2013, we sent a donation of 320 pulse oximeters to Ghana, to support safer monitoring across every government OR and recovery setting.

Lifebox is a small team, and countrywide programme like this stand on the shoulders of giants. We had incredible partners – the Ghana Association of Nurse Anaesthetists (GANA) and Ghana Health Service (GHS), and well-named champions: Dr Thomas Anabah, consultant anaesthetist and intensivist at Tamale in the northern region of Ghana, and Dr Malvena Stuart Taylor, consultant anaesthetist at Southampton University Hospital (and G.A.S. Partnership colleague, which has strong educational and training links with the Upper East Region of Ghana).

Lives are saved by the anaesthesia provider who understands the physiology and the utility of oxygen monitoring, not the inanimate machine – so training is an essential component of any Lifebox distribution project.

“There is no doubt in my mind the positive impact such training that we have been privileged to provide will be vital to the safety of patients in Ghana,” wrote Malvena, following the conference.

“I say this with confidence, based on the observation of impact I can already see in those hospitals in UER who received a pulse oximeter over a year ago.”

Several months later – it was time to find out.

Shane Patrick Moran, a final year medical student – born in Ghana and excited to get back – spent several weeks visiting hospitals in the Upper East Region. The aim was monitoring and evaluation, but not the coldly remote and modelled method – in person, face to face.

He was able to give the pulse oximetry needs assessment multiple choice questionnaire – used to indicate knowledge improvement and retention at Lifebox training – to 50 nurse anaesthetists.

Results showed widespread understanding of the principles of pulse oximetry, while comparison of a few test scores from those who’d completed them back in Koforidua showed knowledge was holding nicely steady. Comments regarding the educational DVD which comes with each oximeter (and is also available online) were overwhelmingly positive.

Speaking of comments – we were able to catch up with Paddy directly! Let’s switch to Q&A mode…

Professionally speaking, what were your biggest lessons learned on this trip?

Experience of conducting research in a low-resource setting and the challenges which can arise. I learnt that no amount of prior planning can account for all eventualities. A fuel strike, communication issues, missing paperwork, and a minor medical emergency all affected the data collection phase. I especially learnt that the data and records which we take for granted in UK hospitals can be hard to come by in low-resource settings. As a result, data collection was a more complicated task than I’d anticipated.

And personally?

My research would not have been possible without the incredible kindness of my Ghanaian hosts. Their enthusiasm and warmth has stayed with me on returning to the UK. Our visit to sit astride live crocodiles at Paga is another experience I won’t forget!

Having been born in Ghana, the project also gave me an excuse to revisit for the first time. My Ghanaian name ‘Kwabena‘ (meaning Tuesday-born) was a source of great amusement to my friends out there.

What did you find to be successful – and what needs more work?

My project findings met expectations, in so far as the Lifebox donation improved understanding of pulse oximetry and the WHO Surgical Safety Checklist amongst anaesthesia providers.

However, I found that a lack of checklist training for other theatre staff, including surgeons, meant the WHO checklist is hardly ever used in practice. It was revealing to hear one surgeon explain that the checklist is not used because “we are very busy and need to look after the patient first”. Therefore education needs to extend to all professionals involved in surgery if they are to routinely engage with checklists.

What are the specific challenges anaesthesia providers face in Ghana?

At every hospital I visited in Upper East Region, the caseload far exceeded capacity. With one doctor per 40,000 people, the demand for healthcare is huge and unrelenting. The poverty and geographic isolation of Upper East Region makes it hard to recruit doctors from more populous parts of Ghana in the south. The anaesthesia providers have a vast workload in conditions of extreme professional isolation. I came away with huge admiration for their professionalism in such a difficult working environment.

Any surprises?

A memorable moment came during a group teaching session for anaesthesia providers from across the region. After encouraging everyone to share a tricky case where things had not gone as planned, we found that roughly half the room had experienced critical events with the same drug in the same type of obstetric case. It was the first time they had shared their experiences, and by engaging with each other they discussed how to avoid the same scenario in future.

Opportunities for this type of reflective practice are few, but improving with help from Lifebox and the G.A.S. partnership (between Ghana Health Service and University Hospital Southampton).

What do you think has been the biggest impact of the Lifebox education and distribution work?

The biggest impact of the Lifebox education and distribution project in Ghana has been to equip every theatre in Upper East Region with pulse oximeters, while ensuring correct interpretation of low SpO2 by clinicians who use oximetry. My project found all anaesthesia providers recognised low saturations and knew how to respond. I also believe the Lifebox anaesthesia logbook is crucial to improving patient safety.

Since the training, anaesthesia providers have recorded critical events in their logbooks, allowing for reflective practice and professional development. Lack of engagement with the WHO checklist is the main area where I feel the continuing efforts of Lifebox are still needed.

This is a map of where to find fish in Lake Malawi. The 3 million year old basin lapping against the ‘The Warm Heart of Africa”s eastern border has a unique biodiversity of cold-blooded residents.

This is a map of the voter breakdown during Malawi’s fourth multi-party election, in 1993.

And this is a map showing the start point of every patient arriving for surgery at the Fistula Care Centre in the capital city, Lilongwe: hundreds of women from dark corners of small rooms in rural villages across the country, living with the permanent incontinence of obstetric fistula. Usually in isolation, locked out of society mourning their baby, their dignity, their place in society.

Maps can teach you a lot of different things, but of course it depends what you’re looking for.

In the last month Lifebox has joined two trips to Malawi, plotting a route directly towards the country’s anaesthesia providers. Without them the fish will keep jumping and the politicians will keep campaigning – but victims of road traffic accidents will never be stitched up, fistula women will never be dry, and mothers in obstructed labour will continue to struggle and tear and lose their babies and join these neglected ranks.

Unfortunately it wouldn’t take long to put them on the map: there are just a few hundredclinical anaesthetic officers in Malawi, and fewer than fiveMalawian medical anaesthetists for a population of 16.4 million. (Compared with more than 10,000 for a population of 64 million in the U.K.)

A small group of visiting medical anaesthetists effectively doubles the country statistics.

In August, Lifebox trustee Dr Isabeau Walker travelled with long-time Lifebox friend and president of the College of Anaesthetists of Ireland Dr Ellen O’Sullivan to Queen Elizabeth Central Hospital in Blantyre, in the south of the country.

They were working with Cyril Goddia, who heads the hospital’s Anaesthesia Clinical Officer training programme. A survey he undertook last year with Gradian Health Systems revealed a significant pulse oximetry gap. So we set about a project to close it.

Some anaesthesia colleagues travelled 10 hours to get to Blantyre, from small rural hospitals across the region. They were working without pulse oximeters, or having to share one between two to four theatres. Basic monitoring was a finger on the pulse and an eye on the colour of the patient’s lips…

Thanks to the Cycling Surgeons, who took on hill and dale and puncture in the name of safer surgery, to the College of Anaesthetists of Ireland (COI) who led the faculty alongside our Malawian colleagues, we were able to donate 100 pulse oximeters and deliver training to 80anaesthesia providers and 20 clinical officer surgeons.

“Thousands of lives will be safer as a result of all your efforts,” Dr Walker reported back. Of the photo from the course – “The smiles say it all!”

Two weeks later we were back in the north, at Kamuzu Central Hospital with ACTS – the African Conference Team led by Dr Keith Thomson. This three-day conference (in the ‘Warm Heart of the Warm Heart’, according to Fanny Mtambo, who supports the UNC Project-Malawi) was an opportunity to improve practice in an area of anaesthetic care that makes up almost 80% of emergency cases: obstetrics.

Think about surgery and (much like toast in a toaster) who comes to mind – the surgeon. But think again about an operation at its most basic level – scalpel rending skin – and imagine it without anaesthesia. It’s the difference between modern medicine and torture, but it’s often overlooked.

This workshop, with support from the Gloag Foundation and UNC, was an opportunity to support the skills, the concerns and the community spirit of a group who know more than any other that something needs to be clear:

“There is no surgery without anaesthesia.”

Explained William Banda, a medical anaesthetist working at Kamuzu: “You can train 100 surgeons – but there will be no operation.”

This shouldn’t be news – but since the message is still lacking, we’re delighted to see that it was!

MBC TV, the main television station in Malawi, sent two journalists and a camera to the conference, to meet the delegates and shine a lens on the vital role of anaesthesia in safe motherhood. It’s possible that they zoomed in on more than expected – a visit to the maternity ward moved quickly from theory to practice – and a gown, mask and a brightly beeping corner of an operating room as a baby was born by emergency C-section.

“Bringing life into this world is an exciting experience,” narrates the journalist, “but at times it can be life-threatening…However there is no surgery without anaesthesia, as anaesthetists play a crucial role in an operation.”

The report was screened twice in 24 hours. What was the response?

“We didn’t know, they say,” explained Marie. “We didn’t know you needed all this to deliver, to survive.”

This is a map of how far delegates at the Lifebox pulse oximetry workshop travelled to get to Blantyre – making the long journey by crowded bus, by bike, from all over the southern region. They came to learn about safer surgery, and take an oximeter back to keep their patients safer.

There are so many more maps we need – where pulse oximeters and training are urgently needed next. Where women wait for fistula repair surgery – or soon will, if they can’t get to a hospital. Where safe surgery is taking place – and where we support the equipment and training to make it evem safer, so that providers and families aren’t forced to make terrible choices to do their jobs or save the people they love.

Not every comic is meant to be funny. While the Scottish city of Dundee’s classic troublemaker Dennis the Menace always lunged for the elbow, one of its newer residents has gone for the incision.

Handiwork: surgery in sequential art, by Emmanouil Kapazoglou, adapts the comic strip format to tell a serious story that is both strange and familiar.

It follows a typical operation on a typical day for a surgical team at the Tayside NHS Trust. Through the prism of the World Health Organization (WHO) Surgical Safety Checklist, we’re taken on a step-by-step journey of the pulse points and timeframes of a surgical procedure.

Scroll slowly. The panels, as with any comic strip or the boxes on the Checklist itself, can only succeed in linear, deliberate steps.

First through the photographs and then through illustrations of those real life images, past the swinging doors and under the hot lights.

Watch as the seeming chaos of masked faces and machines reveals its tightly-rehearsed order – and the team’s intense focus on the safety of the one person not expected to play a role, the reason they’re all here: the patient, lying insensate on a table in the middle of the room.

You’re completing your masters in Medical Artat the Duncan of Jordanstone College of Art and Design, but this still seems like an unusual subject! What led you to the comic strip and the operating room?

Comics are so important in medical education. They have a visual impact and a strong message, but they’re also a helpful generalisation – they can expand the experience of an individual into human experience regardless of gender, age, nationality etc.

They can also speak to the non-medical community, and I was interested to see how they could translate what goes on in an operating room. I wanted to capture the teamwork necessary for a successful surgery.

What surprised you about the operating room?

How calm it was. Medical dramas on TV make it seem stressful – what a misrepresentation. The OR was such a calm place.

Why did you choose the Checklist?

I wanted to show something constant, and the Checklist is the backbone of how surgery happens nowadays. I was very surprised to find out how recently it was introduced – and how difficult it is to change certain patterns of behaviour when people have learned to be kings in their theatres.

Did you see it have an impact?

Seemingly small things, like an allergy not noted down – that could have been catastrophic, but the Checklist caught it. The simple communication it allows between the theatre staff, between the anaesthetist and the ward nurse – there’s a human life on the line, it’s essential.

Did you feel like patients were in safe hands?

The teamwork at Ninewells is inspiring. There’s no place for egoism or career advancement in that room – everything happens for the safety of the patient.

It’s a powerful thing.

Yes, I find that very moving. The vulnerability of the patient under anaesthesia – it’s a person at their most vulnerable, unconscious and surrounded by so many people.

To find that calm mood, and all these people working together – it’s very tender in a way.

Has it changed the way you think about surgery around the world?

I was looking on the Lifebox website and I was shocked – I never thought that lack of oximetry was an issue in so many countries.

You show the Checklist twice, once in photos and once in paint – why is that?

After the second viewing we thought that the pictures might be too intense for someone about to undergo surgery. The drawings are a simplification, and even though they’re the same scenes, people seem to prefer them. There are lots of things you don’t want to know before the operation – other than that you are going to be safe.

They’re very vivid!

I used an impressionistic technique called speed painting where you set a timer, start painting and as soon as the timer goes off, you stop. It makes you keep only the most important aspects of the scene.

How did you relate to the Checklist it as a non-medic?

Checklists happen everywhere. It’s this methodology, a frame of mind behind a sequence of events that shows how teamwork is realised. I used to work as a production assistant at dance festivals – without a checklist we’d never be able to have a performance.

I found the surgical pause particularly poetic. A moment’s thought, everybody stops – it’s like this breath that a performer takes when they go on stage. The lights, the audience, the safety protocol – it’s no joke that the operating room is also called a theatre!